PROGRAM STUDI PENDIDIKAN NERS

STIKes PATRIA HUSADA BLITAR

ASUHAN KEPERAWATAN KELUARGA

Hari :
Tanggal :
Jam :

1. DATA UMUM
a. Nama Kepala Keluarga : .
b. Umur KK : .
c. Alamat dan telepon : .
d. Pekerjaan KK : .
e. Pendidikan KK : .
f. Agama KK : .
g. Suku bangsa KK : .
h. Komposisi keluarga : .
No. Nama Jenis Hub. dg Umur Pendidikan Agama Pekerjaan
Kelamin KK
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
i. Genogram
 PROGRAM STUDI PENDIDIKAN NERS
STIKes PATRIA HUSADA BLITAR

j. Tipe Keluarga
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k. Suku Bangsa
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l. Agama
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m. Status sosial ekonomi keluarga
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n. Aktivitas rekreasi keluarga
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2. RIWAYAT TAHAP PERKEMBANGAN KELUARGA

a. Tahap perkembangan keluarga saat ini
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b. Tahap perkembangan keluarga yang belum terpenuhi
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c. Riwayat kesehatan keluarga inti
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d. Riwayat kesehatan keluarga sebelumnya
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3. LINGKUNGAN
a. Karakteristik rumah
Denah rumah
 PROGRAM STUDI PENDIDIKAN NERS
STIKes PATRIA HUSADA BLITAR

b. Keadaan lingkungan dalam rumah

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c. Keadaan lingkungan di luar rumah
Pemanfaatan halaman
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Sumber air minum
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Pembuangan air kotor
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Pembuangan sampah
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Jamban
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Sumber pencemaran
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Sanitasi rumah
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d. Karakteristik tetangga dan komunitas
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e. Mobilitas geografi keluarga
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f. Perkumpulan keluarga dan interaksi dengan masyarakat
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g. Sistem pendukung keluarga dan ecomap
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4. STRUKTUR KELUARGA
a. Pola komunikasi
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STIKes PATRIA HUSADA BLITAR

b. Struktur kekuatan atau kekuasaan keluarga

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c. Struktur peran (formal dan informal)
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d. Nilai dan norma
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5. FUNGSI KELUARGA
a. Fungsi afeksi
Kebutuhankebutuhan keluarga, polapola respon
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Hubungan keakraban
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Pertalian hubungan (diagram kedekatan dalam keluarga)

Perpisahan dan kekerabatan
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b. Fungsi sosial
Cara pola asuh pada anak
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Siapa yang menjadi pelaku sosialisasi anakanak
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Nilai anakanak dalam keluarga
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Keyakinan budaya yang mempengaruhi pola asuh
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 PROGRAM STUDI PENDIDIKAN NERS
STIKes PATRIA HUSADA BLITAR

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Pengaruh kelas sosial dalam pengasuhan
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Estimasi resiko masalah pengasuhan
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Kelayakan lingkungan rumah untuk bermain bagi anak
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c. Fungsi perawatan kesehatan
Keadaan kesehatan
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Kebersihan perorangan
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Penyakit yang sering diderita
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Penyakit keturunan
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Penyakit kronis atau menular
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Kecacatan
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Pola makan
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Pola istirahat
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Ketergantungan obat atau bahan
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Mencari pelayanan kesehatan
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d. Fungsi reproduksi
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STIKes PATRIA HUSADA BLITAR

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6. STRESS DAN KOPING KELUARGA

a. Stressor jangka pendek dan jangka panjang
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b. Kemampuan berespon terhadap stressor
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c. Strategi koping yang digunakan
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d. Strategi adaptasi disfungsional
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7. PEMERIKSAAN FISIK
Hari :
Tanggal :
TB BB LILA TD N R S
No Nama Keterangan keluhan
Cm Kg Cm Mm/Hg x/ x/ C
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

8. HARAPAN KELUARGA TERHADAP PERAWATAN KESEHATAN KELUARGA

a. Persepsi terhadap masalah
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b. Harapan terhadap masalah
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Perawat yang mengkaji,